ACLS | Post Arrest Care Extended

High-Performance CPR & Perfusion Metrics

• Compressions: Rate 100-120/min at a depth of ≥2 inches (5 cm) with complete chest recoil[1][2].
• Chest Compression Fraction (CCF): Target >80% to maximize coronary perfusion pressure[2][3].
• Capnography (PETCO₂): Continuous waveform monitoring; values <10 mmHg indicate poor CPR quality, whereas an abrupt sustained rise to ≥40 mmHg signals Return of Spontaneous Circulation (ROSC)[1].
• Coronary Perfusion Pressure (CPP): Target CPP (or arterial relaxation pressure) ≥15–20 mmHg to achieve ROSC[2][5].

Adult Cardiac Arrest Algorithm (80/20 Prioritization)

1. VF / Pulseless VT (Shockable Pathway)

• Defibrillation: Immediate 1 shock (Biphasic: 120-200 J; Monophasic: 360 J), then immediately resume CPR for 2 minutes[1][7].
• Epinephrine: 1 mg IV/IO every 3-5 minutes starting after the second shock[1][8].
• Antiarrhythmics: Amiodarone (300 mg IV/IO bolus; 2nd dose 150 mg) or Lidocaine (1–1.5 mg/kg 1st dose; 2nd dose 0.5–0.75 mg/kg) after the third shock for refractory VF/pVT[1][9].

1. PEA / Asystole (Non-Shockable Pathway)

• Immediate Action: No shock. Resume CPR for 2-minute cycles immediately[1][10].
• Epinephrine: 1 mg IV/IO as soon as vascular access is available, repeated every 3-5 minutes[1][11].
• Reversible Causes (H's & T's): Identify and treat Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypo-/Hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade (cardiac), Toxins, Pulmonary thrombosis, or Coronary thrombosis[1].

Airway & Ventilation Strategies

• Unadvanced Airway: 30:2 compression-to-ventilation ratio[1][15].
• Advanced Airway: Insert ETT or supraglottic airway; confirm placement with waveform capnography[1].
• Ventilation Rate: 1 breath every 6 seconds (10 breaths/min) with continuous chest compressions[1]. Avoid hyperventilation to prevent reduced venous return[1].

Post-Cardiac Arrest Care (ROSC Management)

• Oxygenation & Ventilation: Titrate FiO₂ for SpO₂ 92–98%; maintain PaCO₂ at 35–45 mmHg[14].
• Hemodynamics: Target SBP >90 mmHg or MAP >65 mmHg using fluid boluses or pressors (Norepinephrine 0.1–0.5 mcg/kg/min, Epinephrine 2–10 mcg/min, or Dopamine 5–20 mcg/kg/min)[14].
• Reperfusion: 12-lead ECG; emergent PCI for STEMI or unstable cardiogenic shock[14].
• Targeted Temperature Management (TTM): If comatose, maintain core temperature at 32-36°C for ≥24 hours[13].

Special Situations

• Pregnancy: Perform manual left lateral uterine displacement; prepare for perimortem cesarean delivery within 5 minutes if no ROSC[17][23].
• LVAD: Check hum/power; perform compressions only if MAP ≤50 mmHg or PETCO₂ ≤20 mmHg and restart fails[24][25].